Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

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Quality Measures Challenging in Pharmaceutical Value-Based Contracts

October 17, 2017 - Healthcare payers may find it difficult to establish value-based contracts (VBCs) with pharmaceutical companies due to the challenges of creating meaningful, workable quality measures.   Pharmaceutical companies are generally reluctant to engage in value-based reimbursement contracts, says a recent PricewaterhouseCoopers survey, with 61 percent stating that negotiations with payers often...


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Payers Driving Value by Promoting Connected Care Models

by Thomas Beaton

As payers vie to remain competitive in commercial insurance markets, they must be able to effectively manage consumer costs while providing beneficiaries the best possible healthcare experience now and in the future. Rising healthcare costs are...

Planning for Individual Insurance Exchange Stabilization in WA

by Thomas Beaton

State health insurance markets and their individual insurance exchanges have faced regular instability in the form of payer exits, imbalanced risk pools, and rising premiums that push out new and returning insurance consumers. As premiums go...

Medicaid Analytics Support Social Determinant Incentive Payments

by Thomas Beaton

Payers looking for innovative ways to control the costs of care have been turning their attention to the social determinants of health, the non-clinical factors that often lead to issues with care access, non-adherence, and the development of...

CMS Bundled Payment Models Lead to Greater Patient Selectivity

by Vera Gruessner

What are some of the biggest problems around bundled payment models and value-based care causing difficulties for physicians? According to Corporate Director at Willis-Knighton Health Systems Chris Mangin, the Comprehensive Care for Joint Replacement...

How Payers Could Assist Primary Care Docs with Value-Based Care

by Vera Gruessner

How can health insurance companies improve their relationship with primary care practices? How can payers work with primary care providers to expand value-based care reimbursement?  For answers to these questions, HealthPayerIntelligence.com...

Highmark Partners with Aledade’s Accountable Care Organizations

by Vera Gruessner

In December 2016, Aledade Inc., a leader of accountable care organizations (ACOs), and Highmark Blue Cross Blue Shield announced in a company press release a new partnership to provide quality medical treatment through accountable care organizations....

UnitedHealthcare Partners with Accountable Care Organizations

by Vera Gruessner

In December, UnitedHealthcare announced in a company press release the release of NexusACO, a new health plan option for self-funded employers that is available in 15 markets. Tier 1 of NexusACO involves offering healthcare access to members...

Why Healthcare Bundled Payment Models May Expand in 2017

by Vera Gruessner

The Centers for Medicare & Medicaid Services (CMS) have advanced bundled payment models by implementing these value-based payment structures in orthopedic and cardiac care. CMS released a finalized bundled payment model for cardiac and orthopedic...

Communication Key for Transition to Alternative Payment Models

by Vera Gruessner

Along with health insurers, more and more providers are expected to transition to alternative payment models (APMs) especially due to MACRA’s Quality Payment Program. For example, urology group practices are likely to adopt advanced alternative...

How Payers Could Improve Population Health Management with Tech

by Vera Gruessner

When payers transition their reimbursement structures toward a value-based care payment model, healthcare quality improvement needs to be addressed. In order to boost quality, payers could target population health management and data analytics...

UnitedHealth Adopts Bundled Payment Model for Orthopedic Care

by Vera Gruessner

Healthcare payers are finding that their reimbursement totals show higher spend for hip, knee, and spine surgeries and other orthopedic care when compared to other forms of treatment. Along with the higher spend, members regularly show poor health...

Clinical Data Analytics Key for Value-Based Care Reimbursement

by Vera Gruessner

Many medical facilities have seen how the healthcare industry has been moving away from fee-for-service payment to value-based care reimbursement. Revere Health is one organization that jumped on the bandwagon early on and has quickly moved forward...

Why Value-Based Care Reimbursement, MACRA are Here to Stay

by Vera Gruessner

The outcome of the presidential election has led to some uncertainty throughout the healthcare industry when it comes to legislative changes and medical coverage. However, providers and payers will need to keep a clear head in the coming months...

Humana Serves 63% of Members through Value-Based Care Payment

by Vera Gruessner

The future for the health insurance industry likely revolves around value-based care payment, which has grown in use steadily over the last several years. Recent healthcare reforms have centered around tracking the quality of care, reducing spending,...

Quality Metrics Pose Problems for Value-Based Care Reimbursement

by Vera Gruessner

The healthcare industry’s fast pace transition to value-based care reimbursement has led to some major challenges for both providers and payers. Adopting completely new payment contracts based on quality metrics is not a simple maneuver...

Payers Benefit from Aligning with MIPS, Value-Based Care

by Vera Gruessner

While healthcare regulations like MACRA legislation often centers around impacting medical providers, the health insurance industry is also integrated into the tapestry of value-based care and alternative payment models. When providers start...

Rise in High-Deductible Health Plans Requires Cost Transparency

by Vera Gruessner

High-deductible health plans are becoming more and more common across the health insurance industry. With the many changes that the Affordable Care Act (ACA) has brought, payers are attempting to control costs by offering more high-deductible...

How to Favorably Manage Risk in Value-Based Care Reimbursement

by Vera Gruessner

While downside risk does not incentivize providers to take part in value-based care reimbursement policies, data-driven technology and a combination of financial motivations may encourage physicians to transition to alternative payment models,...

Why Reviewing Pricing Trends is Key for Bundled Payment Models

by Vera Gruessner

When payers begin to adopt bundled payment models, they may find some challenges standing in their way to truly succeed within these alternative payment solutions. For example, when attempting to contract through bundled payments, it may be difficult...

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